Safety Núm. 18 Boletín de Seguridad Operacional para personal de EVELOP y ORBEST
Junio 2017
NOTA: Las sugerencias, opiniones y noticias expresadas en este boletín no son necesariamente las de Evelop Airlines S.L. y Orbest S.A. Los datos que se ofrecen en este boletín no sustituyen ni deben ser tomados como información oficial. Ningún artículo en este boletín pretende sustituir normativas, procedimientos publicados, ni recomendaciones del fabricante, el operador o el Estado. Este boletín está dirigido en exclusiva al personal de las compañías Evelop Airlines S.L. y Orbest S.A.
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¿Qué hay de los SISTEMAS DE GESTIÓN DEL RIESGO DE LA FATIGA (FRMS)?
l Reglamento (EU) 965/2012 AIR-OPS en su parte ORO, subparte FTL establece los requisitos que deben cumplir los operadores aéreos y sus tripulaciones con respecto a las limitaciones de tiempo de vuelo y de actividad y a los requisitos de descanso para los miembros de la tripulación. Estas regulaciones se traducen en su incorporación en nuestro Manual de Operaciones sección A7, que recoge las limitaciones de tiempos de vuelo y actividad y requisitos de descanso, de acuerdo a la normativa arriba mencionada, efectiva desde el 18 de febrero de 2016. Como parte importante de la adaptación de la norma, todos los FC & CC y demás personal operativo implicado en la programación, gestión de flota, despacho, etc. ha recibido la formación adecuada mediante el curso FLIGHT TIME LIMITATIONS (FTL) Y GESTIÓN DE LA FATIGA DE LAS TRIPULACIONES, formación que pretende, por un lado facilitar a las tripulaciones información detallada sobre el marco regulatorio actual en materia de limitaciones de actividad, tiempos de vuelo y requisitos de descanso y, por otro lado y lo más importante, que seamos capaces de identificar situaciones de fatiga,
Actualmente estamos aquí ero un Sistema de Gestión del Riesgo de la Fatiga (FRMS) es más que esto. Una vez esté implementado, deberá disponer de procesos definidos para la:
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Responsable: Joan Fiol joan.fiol@evelop.com 618 740499 Coordinador SMS: Luis Castaldo luis.castaldo@evelop.com 971 448034 Oficial Seguridad / FDM: Raúl Castiñeira raul.castineira@evelop.com Oficiales de Seguridad:
las causas de la misma, sus repercusiones y las medidas para su prevención y mitigación.
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Dirección de Seguridad Operacional
Identificación de peligros relacionados con la fatiga, Definición de indicadores y objetivos que ayuden a controlar los niveles aceptables de fatiga, Propuesta de medidas mitigadoras de las situaciones identificadas como generadoras de fatiga,
Mantenimiento > MNT Javier Moragues TCPs > CAB Isabel Abela Ops Vuelo > FLT Carlos Magaz Raúl Castiñeira Oficina Técnica > OFT Tolo Font OCC > DSP Steve Nicoll Ops Tierra > GRH Rafael Rodríguez Entrenamiento > TNG Álvaro Sabater
Monitorización del cumplimiento de objetivos planteados,
… y ello implica una completa y armonizada integración en nuestro propio Sistema de Gestión (SMS). A pesar de que la actual norma todavía no requiere tener aprobado y mantener un FRMS a los operadores, en EVE & OBS hemos dado los primeros pasos hacia la definición de los procesos adecuados siguiendo los criterios inicialmente marcados por nuestras Autoridades y la industria en general.
EVELOP Airlines, S.L. Avda. 16 de julio, 75 (Edif. Barceló) 07009 - Palma de Mallorca (Illes Balears) - España
¿Tienes alguna sugerencia para mejorar este boletín? ¿Deseas que se trate algún asunto específico relacionado con la Seguridad? ¿Echas en falta alguna sección o quieres colaborar con algún artículo? safety@evelop.com EVELOP Airlines
Boletín de Seguridad Operacional #18—Junio 2017
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FATIGUE AND SLEEP LOSS IN AVIATION
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SOME DATA
n January 25, 2016, in darkness and hazy weather condiOn 2006 a study at UCE Birmingham on the effect of fatigue on tions, the flight crew of an ATR 72 lined up the aircraft on 162 short-haul pilots reported 75% of the pilots had experienced the runway edge lights along the right-hand side of runway severe fatigue with 81% consi27L instead of the runway centerline lights of runway 27L. dering the fatigue to be worse This resulted in a misaligned take-off roll over the elevated runway than two years previously. edge lights along the right-hand side of runway 27L leading to daOn 2012 the European Cockpit mages to the runway edge lights and the aircraft itself. Association carried out a survey A combination of environmental, operational, and human factors about self-assess of the level of fatigue experienced by pilots. contributed to the sequence of events: More than 6.000 European ⇒ Dark night operation pilots were surveyed between 2010 and 2012 and the results ⇒ Reduced visibility ⇒ Runway and taxiway environment, including an extra tar- were published as Barometer on mac width on runway 27L, the absence of runway shoulder Pilot Fatigue. Some of the surmarkings, the absence of taxiway centerline lighting, and vey results are: the use of a displaced threshold
⇒ Flight crew divided attention unintentionally provoked by the before take-off procedures and checks ⇒ Flight crew fatigue The serious incident occurred in dark night and under instrument meteorological conditions (IMC). Despite the fact that the actual flight and duty time of the flight crew did not violate any flight and duty time requirements, the Danish Investigation Authority considered the flight crew to be fatigued in the morning of the accident day. Because of fatigue, flight crew performance was impaired equivalent to more than 0.05% blood alcohol concentration impairing flight crew vigilance and reaction times and might have impaired the flight crew decision- making process and the flight crew night vision adaptation and visual acuity. Sleep loss and circadian disruption created by flight operations can degrade performance and alertness, we all know that. Scientific examination of these psychological/physiological parameters has established a direct relationship between their degradation and errors, incidents and accidents. We all know that, too. Nevertheless, despite that knowledge, fatigue remains an ever present danger in flight operations. The operational demands of the aviation industry and the growth in global long-haul, regional, overnight, and short-haul operations will continue to increase the 24hour/7days requirement on flight crews. Therefore, shift work, night work, irregular work schedules, unpredictable work schedules, and time zone changes will continue to be commonplace components of the aviation industry. These factors pose known challenges to human physiology, and because they result in fatigue and performance impairment they pose a risk to safety. Extensive data are available that clearly establish fatigue as a significant safety concern in all modes of transportation and in 24-hr shift work settings. The safety risk posed by human fatigue in transportation has been recognized and addressed over 100 years. Its 24/7 operational demands can easily lead to degradation or impairment in all aspects of human capability particularly cognitive performance including decision-making, attention, reaction time, learning, memory and communication skills. When individuals performing safety-critical functions are affected by fatigue, there is a high risk of fatalities, injuries and environmental hazards as a result of accidents or incidents. Additionally, there are other associated costs of fatigue, such as the financial costs of reduced productivity and potential liability issues.
EVELOP Airlines
• Over 50% of surveyed
pilots reported having experienced fatigue as impairing their ability to perform well while on flight duty.
• 4 out of 5 pilots reported having coped with fatigue while in the cockpit, according to polls carried out in Austria (85%), Sweden (89%), Germany (92%) and Denmark (93%).
• In the UK (43%), Denmark (50%), Norway (53%) and Sweden
(54%) the surveyed pilots reported falling asleep involuntarily in the cockpit while flying. In the UK, a third of the pilots said to have woken up finding their colleague sleeping as well. 65% of Dutch and French pilots stated they have trouble with “heavy eyelids” during flight.
• 70-80% of fatigued pilots would not file a fatigue report or declare to be unfit to fly. Only 20-30% will report unfit for duty or file a report under such an occurrence.
• More than 3 out of 5 pilots in Sweden (71%), Norway (79%) and Denmark (80-90%) acknowledge having already made mistakes due to fatigue, while in Germany it was 4 out of 5 pilots.
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n August 2013 was published the study Prevalence of Fatigue in a Group of Airline Pilots based on a 2012 survey of 1500 commercial airline Portuguese pilots, commanders (captains) or first officers between the ages of 20 and 65 who were on active duty and had flown during the previous six months. The assessed their fatigue using the nine-item Fatigue Severity Scale. Some of the results of the study are:
• More than 90 percent reported having made fatigue-related mistakes in the cockpit
• 66% said that they had more than once been so tired that they should not have been at the controls
• Despite they admitted having been fatigued while flying, 82%
said they had never reported themselves as “unfit for flight as a result of accumulated fatigue,” and only 11 percent said they had done so only once
• Pilots flying medium- and short-haul flights —typically less than six hours long with multiple legs — reported higher levels of fatigue than those who flying long-haul flights.
Human fatigue can have a role in accidents causation by producing performance impairment when the individual is awake, or by inducing microsleeps or producing an uncontrolled and unintentional full sleep episode.
Boletín de Seguridad Operacional #18—Junio 2017
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(Cont.) FATIGUE AND SLEEP LOSS IN AVIATION
HOW CAN PILOTS BECOME FATIGUED?
kedly impair various aspects of performance including attention, reaction time and co-ordination. Humans simply are not designed to atigue refers to a physiological state of reduced mental or operate under the pressured 24/7 schedules that often define aviaphysical performance capability in which there is a decreased tion operations, whether the operations are short-haul commercial capacity to perform cognitive tasks and an increased variabili- flights, long-range transoceanic operations, or around-the-clock and ty in performance. It is an enabler of poor judgment and decision- shift work operations. making, slowed reaction times, and loss of situational awareness and control. It degrades a person’s ability to stay awake, alert, and Because performance and alertness levels are largely influenced by attentive to the demands of controlling a vehicle safely. the complex interaction between sleep and the 24-hour biological clock, the cited factors determine in a predictable way the background level of fatigue/alertness at any given moment.
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The various factors that contribute to fatigue are individually capable of causing dangerous impairments in performance. Using a standardized performance test in, both, sleep loss and alcohol consumption conditions, investigators could provide a blood alcohol concentration metric to compare results from the sleep loss condition. Results demonstrated that after 17 hours of continuous wakefulness, cognitive psychomotor performance decreased to a level equivalent to a blood alcohol concentration of 0.05%. After 24 hours of continuous wakefulness, performance was approximately equal to a blood alcohol concentration of 0.10%.(Dawson D and Reid K. Fatigue, alcohol and performance impairment. Nature, 388:235, 1997.) Fatigue increases the desire to obtain sleep. It is also associated with tiredness, weakness, lack of energy, lethargy, depression and lack of motivation. To make matters worse, fatigue actually impairs the ability to self-judge just how fatigued the person is. Fatigue results from an imbalance between: The physical and mental exertion of all waking activities (not only duty demands); and
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Recovery from that exertion, which, except for recovery from muscle fatigue, requires sleep. It is associated with sleep loss, extended wakefulness, high mental and/or physical workload, long unbroken periods of work -known as ‘time-on-task’ fatigue-, and circadian phase. In addition, there are acute influences such as monotony, boredom and environmental factors at the workplace (i.e. at the airport during long breaks or on the flight deck) that can interact with the factors cited above to precipitate the apparition of fatigue.
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There is a discernible pattern of increased probability of an accident as duty time increases for commercial aircraft pilots. For 10-12 hours of duty time, the proportion of accident pilots with this length of duty period is 1.7 times as large as for all pilots. For pilots with 13 or more hours of duty, the proportion of accident pilot duty periods is over five and a half times as high. 20% of human factor accidents occurred to pilots who had been on duty for 10 or more hours, but only 10% of pilot duty hours occurred beyond the 10th duty hour. Similarly, 5% of human factor accidents occurred to pilots who had been on duty for 13 or more hours, where only 1% of pilot duty hours occur beyond the 13th duty hour. The greater the hours of duty time for pilots the greater probability of an accident. The ability of aircrew to sustain levels of alertness during long flight duty periods has been the subject of many scientific investigations. There is an interaction between time of day, or circadian factors, on the one hand, and time since sleep and time on task on the other, with the result that duties at certain times of day are particularly susceptible to the effects of fatigue:
Sleep loss and extended wakefulness
1. Night duty (flights ending during / extending through the Window of Circadian Low- WOCL): Night duty hours are espeeveral factors are involved in the development of a loss of sleep cially vulnerable to severe fatigue. The longer the duty period exand fatigue in aviation: less-than-optimal sleeping conditions, tends the greater the pressure for sleep becomes, and there is early reporting time, rotating and non-standard work shifts, night strong evidence to show that many crews fall asleep, either voluntaduty, the time on duty, long spans of wakefulness during the worrily or involuntarily, on the flight deck. The longer the flight, the king day, the number of sectors, the number of time- zones crossed greater the risk that both pilots will fall asleep at the same time. and the number of consecutive flying days. Their ability to respond to an emergency situation, or to land the There are other factors, like stress, disease, noise, vibrations/ plane in adverse conditions, may also be severely impaired. movement, or an upright sleep posture that can also influence sleep 2. Duty during day time – early departures: Whereas long duty quantity and quality. Indeed, it should be emphasized that 8 hours hours can be sustained during many day-time flights, specific proof sleep may fail to provide restitution if it is highly fragmented as a blems are associated with early starts. Early start times are inevitably result of these or other disturbing factors. This is particularly likely to associated with a loss of sleep, the result of which is lower levels of be the case with sleep taken during the day when a range of envialertness throughout the entire duty period. The effect is exacerbated ronmental factors often contributes to sleep disturbance. over several successive early starts, due to an accumulating sleep The main cause of problems associated with the unusual rest and deficit.
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activity patterns experienced by aircrew is the conflict with the biological clock which synchronizes our activity with that of the environment. This clock guides the circadian rhythm by activating the body, through increased metabolism during the day, and reduced levels at night, to promote recuperation. The result is an increased alertness during the day and lowered wakefulness and functional capability at night, being the lowest point of performance at around 05:00h (Window Of Circadian Low-WOCL). The reduction in performance at the lowest point during WOCL is severe and will mar-
EVELOP Airlines
However, the most serious problems arise when the factor combine to provide even larger impairments. Night duty will involve work at the circadian low and an extended time awake. The two together will cause psychomotor impairment similar to that which is seen after the ingestion of enough alcohol to generate a blood alcohol level of 0.08% (which is significantly beyond the drink-drive limit in most European countries).
Boletín de Seguridad Operacional #18—Junio 2017
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f the lack of sleep extends into the next day (comparable to the late morning after a 6-hour time-zone crossing without any postflight sleep), there is a large impact on memory processes – with an impairment in the ability to respond to changed circumstances. The effects are further exacerbated in the event that prior sleep (i.e. before the flight/night duty) has also been disturbed.
(Cont.) FATIGUE AND SLEEP LOSS IN AVIATION hours of sleep per day will be equivalent, in terms of fatigue and performance, to one full night of sleep loss after 5 days. The effects of restricting sleep night after night accumulate so that people become progressively less alert and less functional day after day. This is sometimes described as accumulating a sleep debt. This is a common occurrence for crewmembers when minimum rest periods are scheduled for several days in a row.
Moreover, sleep taken after night duty will be truncated by 1-2 hours, because the circadian rise of metabolism in the morning will he shorter the time allowed interfere with the sleep process. Sleep during the day on layover for sleep each night, the (before commencing another flight duty) is shallow, disrupted and shorter than during the WOCL. This has a detrimental effect on faster alertness and performance decline. Spending 7 hours alertness during the subsequent flight duty. in bed for 7 consecutive nights Time-zone transitions is not enough to prevent a progressive slowing down in lights across 4 or more time zones lead to the disturbance of reaction time. The decline is sleep and circadian rhythms. If in addition, the flight is perfor- more rapid if spent only 5 med at night it magnifies performance decrements and increases hours in bed each night, and the desire to sleep. As a result of these disturbances, more time is even more rapid for those who required to recuperate, both during layover and after return to ba- spent only 3 hours in bed each se, before further flying duty is undertaken. night. This is described as a dose-dependent effect of sleep Night flights from west to east (North America to Europe – Europe restriction. to Asia) have an inherent augmented risk of fatigue. To counter fatigue, some pilots will try to nap before a night–time leg. While The pressure for sleep increathis can be helpful in some cases, it cannot prevent fatigue in all ses progressively across sucpilots. Moreover, it is not always possible to obtain an adequate cessive days of sleep restriction. Eventually, it becomes overwhelamount of good quality sleep during the day and performance de- ming and people begin falling asleep uncontrollably for brief pecrements will persist. riods, known as micro-sleeps. During a micro-sleep, the brain disen-
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In addition, these types of flights are characterized by long periods of darkness with few operational demands while on cruise altitude, creating inherently soporific conditions. It is not until the flight approaches dawn that pilots experience reduced sleepiness as the daylight and circadian rhythms start to alleviate some of the fatigue. Nonetheless, the high workload requirements of approach and landing have to be borne at a time when there is a significant risk of pilot fatigue. Most of these pilots fly a small number of night-time legs per month and revert to sleeping at night when not working. The circadian system of pilots who fly only a small number of night–time legs will not adapt to working at night, and these pilots are likely to display performance decrements during the night–time leg in spite of any countermeasures. Quality of In-Flight Sleep
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rewmembers’ sleep in onboard crew rest facilities is lighter and more fragmented than sleep on the ground. Sleep during flight deck naps is also lighter and more fragmented than would be predicted from laboratory studies. Sleep debt
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sleep deficit of more than 2 hours has a discernible effect on performance capability. An acute reduction of sleep to below 6 hours will cause increased fatigue and reduced performance in most individuals. Sleep loss will also accumulate across time: 5
gages from the environment (it stops processing visual information and sounds. Full recovery of waking function after sleep restriction can take longer than two nights of recovery sleep (i.e., longer than it takes the non-REM/REM cycle to recover). Indeed, chronic sleep restriction may have effects on the brain that can affect alertness and performance days to weeks later.
For the first few days of severe sleep restriction (for example, 3 hours in bed), people are aware that they are getting progressively sleepier. However, after several days they no longer notice any difference in themselves, even although their alertness and performance continues to decline. In other words, as sleep restriction continues, people become increasingly unreliable at assessing their own functional status. This finding raises a question about the reliability of subjective ratings of fatigue and sleepiness as measures of a crewmember’s level of fatigue-related impairment. The sleeprestricted brain can stabilize at a lower level of functioning for long periods of time (days to weeks). Recovery from sleep loss
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ost sleep is not recovered hour-for-hour, therefore, recovery sleep should be longer than usual. The restorative value of sleep quality (sleep quality) depends on going through unbroken non-REM/ REM cycles, which suggests that both types of sleep are necessary and one is not more important than the other. The more the non-REM/REM cycle is fragmented by waking up, or by arousals that move the brain to a lighter stage of sleep without actually waking up, the less restorative value sleep has in terms of how a person feel and function the next day. Once out of duty and given the opportunity to sleep at leisure, on the first recovery night, there is more slow-wave sleep than usual. Indeed, there can be so much slow-wave sleep that there is not enough time to make up REM sleep. On the second recovery night, there is often more REM sleep than usual. Only by the third recovery night, the non-REM/REM cycle is usually back to normal. To reduce crewmember fatigue requires reducing the exertion of waking activities and/or improving sleep.
EVELOP Airlines
Boletín de Seguridad Operacional #18—Junio 2017
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MANAGING FATIGUE RISK
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anaging fatigue is a very complex task that must go far beyond flight/duty/rest time limitations. All the cited factors preclude a simple solution. There is no a simple and unique one-sizefits-all approach strategy that works for everybody. A variety of regulatory actions to address fatigue-related safety risks has been implemented, reviewed and revised. A lot of information has been published, multiple training courses and strategies have been designed. However, fatigue continues to cause and contribute to transportation safety events. Regulators must be aware that flight/duty/rest regulatory schemes loopholes when taken together, and applied in an environment of increasing competition, may encourage, or indeed compel, individual airlines to operate everywhere close to the defined limits by business considerations. In that case, it is likely that this would lead to a significant reduction in the safety of airline operations. There would be a clear competitive advantage for those airlines that operate as close as possible to the limits specified in the regulations, but there would be a significant increase in the risk of fatiguerelated incidents and accidents if operators were permitted to operate to the limits. The complexity and diversity of operational requirements demand a variety of approaches. Concept development should be initiated to move beyond current flight/duty/rest regulatory schemes and toward operational models that provide flexibility and maintain the safety margin. Scientific evidence has remarked the vital importance of adequate sleep, not just rest, for restoring and maintaining all aspects of waking function and the importance of daily rhythms in the ability to perform mental and physical work, and in sleep propensity (the ability to fall asleep and stay asleep). Some Mitigation Strategies that could be taken into account are:
• Proper work/rest scheduling is of primary importance • Duty
periods should not be as long as 12 hours when they surpass the window of circadian low- WOCL
• If
there is early starts the flight duty periods should be shorter than the allowed by the regulations
• There shouldn’t be more than 2 consecutive night duties • There shouldn’t be more than 2 consecutive early starts • Strategic
napping and strategic use of caffeine as alertnessenhancing compound must be considered
• There is good evidence that in-flight sleep improves subsequent
alertness and reaction speed and is a valuable mitigation strategy. The 40 minutes planned rest period provide time for preparation for the rest period, falling asleep, and sufficient length time for an approximately 26 to 30 minutes nap to occur. After the nap, a recovery period of 15-20 minutes allows time for sleep inertia to dissipate if present and to brief the rested pilot before reentering the operational loop. The amount of sleep obtained in cockpit nap does not affect subsequent layover sleep or circadian rest/activities patterns.
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(Cont.) FATIGUE AND SLEEP LOSS IN AVIATION night flight or a flight with a large (= 4 hours) time difference. Thus, even a minimum rest period of 10 hours in many cases may not provide sufficient time for recovery.
• Schedules must be designed to allow periodic opportunities for
recovery and periodically include an opportunity for at least two consecutive nights of unrestricted sleep, to enable crewmembers to recover from the effects of sleep loss. This does not equate to 48 hours off. For example, 48 hours off duty starting at 02:00 would only give most people the opportunity for one full night of unrestricted sleep. On the other hand, 40 hours off starting at 21:00 would give most people the opportunity for two full nights of unrestricted sleep.
• Additional
nights may be needed for recovery if a crewmembers’ circadian body clock is not already adapted to the local time zone.
• Recovery opportunities
(sleep opportunities) need to occur more frequently when daily sleep restriction is greater, because of the more rapid accumulation of fatigue.
• Rest
periods should include defined blocks of time (sleep opportunities) during which crewmembers are not contacted except in emergencies. These protected sleep opportunities need to be known to flight crews and all other relevant personnel. For example, calls from crew scheduling should not occur during a rest period as they can be extremely disruptive.
• Operators should also develop procedures to protect crewmem-
ber sleep at layover and napping facilities. If a rest period occurs during the day at a layover hotel, the operator could make arrangements with the hotel to restrict access to the section of the hotel where crewmembers are trying to sleep (such as no children, crewmembers only) and instruct their staff to honor the necessary quiet periods (for example, no maintenance work or routine cleaning)
• There are computer models that incorporate the schedule infor-
mation and provide an instant evaluation of alertness levels on any given roster. It is possible to compare the effects on fatigue of different rosters and to estimate the effects of modifying the pattern of duty in different ways as well as estimate the probability that either a single pilot or both pilots will be asleep on the flight deck at any particular time
• Good sleep hygiene by flight crew is essential. Therefore, pilots
and other aviation personnel, particularly those performing overnight operations especially during the window of circadian low, must be deeply and recurrently trained about the physiology of sleep and circadian rhythm. The training should include the causes, effects and risks associated with fatigue as well as it’s prevention and mitigation strategies. Personal responsibility during non-work periods, rest environments, and the effects of commuting and/or napping should be stressed too. The fatigue training should include personnel involved in crew scheduling and senior management too.
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anaging fatigue must take into account operational differences and differences among crew members and requires a comprehensive approach that focuses on research, education and training, technologies, treatment of sleep disorders, hours-of-service regulations, and on- and off-duty scheduling policies and practices. Ultimately, fatigue-related accidents can be avoided with a combinaRest is not the same as sleep. A rest period with reduced physi- tion of science-based regulations, comprehensive fatigue risk manacal or mental activity does not produce the same effects of gement programs, and individual responsibility. sleep. Only sleep can reverse the physiological sleepiness.
• Layover
rest periods should provide sufficient time to recover from the immediate effects of the previous flight and to obtain sufficient sleep prior to the next report
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sleep opportunity of 8 hours may not be sufficient after a
EVELOP Airlines
Author: Laura Victoria Duque Arrubla Aviation Medicine, Human Factors and Aviation Safety specialist Blog: Living Safely with Human Error
Boletín de Seguridad Operacional #18—Junio 2017
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MEDICAL URGENCY—PAN PAN, PAN PAN, PAN PAN, Sick passenger on board
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urante el desarrollo de un vuelo reciente de EVELOP desde PMI hacia un aeropuerto de Escandinavia, un pasajero se encontró indispuesto, requiriendo su estado crítico el desvío urgente de nuestro vuelo hacia un aeropuerto alternativo en ruta para recibir asistencia médica: Description from eReport FLT28-17 [...Estábamos en crucero entre Dinamarca y Noruega cuando me avisan por primera vez que un pasajero que había ido al baño, había perdido la consciencia y la había recuperado. Me comenta la jefa que van a pedir un médico y aparecen una enfermera y una médico. La S/C me informa que van a dar oxígeno al pasajero y van a abrir el EMK. Mientras vamos recogiendo información meteorológica de los diferentes aeropuertos y vamos seleccionando las opciones por si empeorase. Al parecer este pasajero había sufrido un ictus hacía poco tiempo y ya en España de vacaciones también tuvo que ir a urgencias. Al cabo de un rato me comenta la jefa que al parecer el pasajero no está respirando bien ni con el oxígeno y la doctora había recomendado que al pasajero le viesen en un hospital rápidamente, que era grave. En esos momentos estábamos a unas 80 NM de Oslo, notificamos al control la situación del pasajero y que requerimos desvío a OSL, directamente nos autorizaron a final de la pista 01R y a mantener alta velocidad como número 1 en aproximación. Durante el descenso notificamos al control el nombre del pasajero su estado y dónde va sentado. Más tarde nos confirma el control que estarán los equipos de emergencia esperando y la posición de parking, nos ofrece la pista 01L que está más cerca de dicho parking y aceptamos. Realizamos el procedimiento de OVERWEIGHT LANDING, pesábamos al aterrizar 65800 kg. Al llegar al parking había un equipo de emergencias esperándonos, directamente entraron por detrás y después de estabilizarlo y hacerle varias pruebas se lo llevaron en ambulancia al hospital, y nosotros continuamos hacia TROMSO…]
RECUERDA:
⇒ Tal como se incluyó en el Safety Bulletin #12 publicado en junio 2016, si existe un problema médico serio a bordo, la señal de urgencia PAN PAN, repetida preferiblemente tres veces, puede ser utilizada por las tripulaciones de vuelo para comunicarlo al ATC. ⇒ Cuanto más clara y más pronto se transmita esta información al ATC, mejor coordinación, eficiencia y anticipación de los procesos de asistencia en tierra. ⇒ Durante la secuencia de aproximación y aterrizaje, el ATC debería dar total prioridad a una aeronave que transporte una persona con problemas médicos serios y requiriendo asistencia médica urgente, haya dado la señal de urgencia o no (OACI Doc 4444). ⇒ La señal PAN PAN MEDICAL únicamente puede ser usada por aeronaves u otros vehículos civiles o militares, permanentes o temporales, dedicados exclusivamente al transporte médico o sanitario controlado por un organismo oficial de una parte involucrada en un conflicto, y no en casos de urgencias médicas que puedan surgir a bordo de aeronaves realizando vuelos comerciales.
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A320—NAV IAS DISCREPANCY DURING TAKE OFF
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urante la carrera de despegue de un vuelo de EVELOP operado con el A320 EC-LZD desde el aeropuerto de Tenerife Norte—Los Rodeos (GCXO/TFN), el copiloto (PF) detecta que su indicación de velocidad no es fiable y transfiere el control del avión al comandante (PM). El vuelo es continuado y se aplican los procedimientos correspondientes, completándose con normalidad: Description from eReport FLT24-17 [...En carrera de despegue, el CM2 como PF, alrededor de 60 kt. se fija en que la velocidad indicada en su PFD cae bruscamente y sube se manera inmediata a 60 kt. CM2 avisa del fallo y me transfiere el control. Chequeamos el PFD1 con el Stby y al ver que coinciden, continuamos la carrera de despegue. La indicación en el PFD2 aumenta muy poco a poco e incluso después de la rotación entra en el ALPHAMAX SPEED en rojo. El ECAM avisa con un MASTER WARNING, NAV IAS DISCREPANCY. Durante el ascenso, la IAS del PFD2 aumenta muy despacio, indicando 210kt mientras el PFD1 y el Stby marcaban alrededor de 300kt. La altitud difiere en 180ft y ya en crucero, M0.78, el PFD2 indica M0.61. Completamos ECAM y el ADR check procedure. Decidimos desconectar el ADR2 y continuamos el vuelo sin más problemas…] a FC aplica los procedimientos operacionales correspondientes ADR CHECK PROCEDURE. El vuelo se continúa sin más novedad. Se ha desconectado el ADR2, supuestamente no fiable. El Cte solicita asistencia de Mantenimiento a la llegada a LEVT/VIT. Personal de mantenimiento realiza tareas de comprobación de sistemas y sondas pitot, no encontrando defectos ni obstrucción. Se despacha el avión. Una vez se regresa a base TFN, ya se han programado nuevas tareas a realizar por parte del personal de mantenimiento para realizar nuevas comprobaciones de sondas y sistemas. Conclusiones: Ingeniería determina que la causa probable de la indicación puede haber sido debido a un insecto que se introduce en el tubo pitot#2 durante la carrera de despegue, aunque durante el vuelo es desintegrado y se elimina a través del drenaje de la propia sonda. No se encontraron evidencias de obstrucción.
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EVELOP Airlines
Boletín de Seguridad Operacional #18—Junio 2017
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A320—L/G LEVER MALFUNCTION—LG NOT DOWNLOCKED WHEN LG LEVER DOWN
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n la fase de aproximación final al aeropuerto de Palma de Mallorca (LEPA/PMI) en un vuelo de EVELOP operado por ORBEST con la aeronave A320-214 CS-TRL MSN3758, la tripulación de vuelo detecta que al selectar la palanca del tren de aterrizaje (L/G LEVER) a la posición DOWN para configurar el avión para aterrizar, éste no se despliega. Tras varios intentos se consigue la configuración adecuada y se aterriza con normalidad. A continuación se incluyen algunos detalles técnicos del suceso: LG did not fall after moving down the LG lever in cockpit (and LG doors did not open either). For three attempts. Then the pilots shaked the lever and at the 4th attempt, they got the LG down. Based on Captain's report the aircraft condition was as follows: Aircraft speed: 160-170 knots with configuration Flaps 2 Flaps & Slats speed were normal. L/G Lever was cycled twice in less than 30 seconds. No response from the L/G System. No ECAM message. After the 3rd L/G cycle, L/G lever was in down position for 4-5 seconds: ⇒ At that time the Indicator light Panel (400VU) showed 3 red UNLK. ⇒ The SD page remained in CRUISE page. With L/G lever in down position (not cycled) the captain shacked and pushed harder the L/G lever to down position. After a couple of seconds: ⇒ The Indicator light Panel (400VU) changed to green triangles, first NLG and then MLG ⇒ Once the green triangles the SD Page changed to WHEELS. ⇒ The L/G deployed correctly. ⇒ No fault or warning related shown at that moment. Corrective actions: On g r o u n d , t h e le v e r -control LG (6GA) electrical connectors were revised and OK. TMAs suspect of internal failure of the 6GA that might intermittently not trasnsmit the command to the LGCIU. Performed AMM task 32-31-00-710-002-A01 - Operational Test of the Landing Gear Doors (Without False Targets), as we can not perform the real Operational Test due to no jacks available to lift the A/C, and everything worked fine, the MLG doors opened and closed during the simulation upon moving down the lever-control LG. Information sent to aircraft manufacturer AIRBUS requesting trouble shooting, obtaining following information: Based on the description of the event provided in communications /001 and /004, Airbus agree with OBS’s plan to replace both LG Lever 6GA and Relay 62GA. Subsequently, OBS need to perform, as a minimum, the tests required in AMM Task 32-31-11-400-001-A (i.e. BITE test of the landing gear + Check of the mechanical integrity of the control lever) before dispatching the aircraft. • LG lever replaced according AMM 32-31-11-400-001-A • Relay 62GA changed. • Performed two tests of AMM 32-31-11-400-001-A: - BITE test of the landing gear, a LGCIU 1 y 2, getting results OK. - Check of the mechanical integrity of the control lever. - Final test performed during next posicional flight.
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IFTB—In-flight Turn Back DUE TO HYDRAULIC YELLOW SYSTEM LEAK
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n la fase de crucero de un vuelo EVE801 MAD-PUJ del día 2 de mayo operado con el A330 EC-MII, la FC recibe la indicación HYD Y RSVR LO LVL s e g u id a d e HYD Y SYS LO PR. U n a v e z r e a liza dos los procedimientos correspondientes, el comandante contacta con OCC y la dirección de EVELOP, y por seguridad se toma la decisión de volver a Madrid para reparar la avería del sistema fallido y reiniciar el vuelo con otra aeronave A330. De acuerdo a la información de Mantenimiento anotada en el TLP EH568, se detecta una junta de un tapón en malas condiciones en el HIGH PRESSURE MANIFOLD, por donde se produce la fuga de fluido hidráulico. Se procede a sustituir la junta PN NAS1612-10 y rellenar el fluido hidráulico perdido. Dando el avión en servicio. Tras investigar la información disponible en AirbusWorld, se descubre que es un problema conocido, para el cual Airbus todavía no ha desarrollado una acción correctora final. No obstante se toman las siguientes acciones: 1. Inspección completa de HP MANIFOLD de los Sistemas AMARILLO Y AZUL. 2. Sustitución de la junta instalada en el HP MANIFOLD del Sistemas AZUL. 3. Añadir inspecciones específicas durante las revisiones A-Check. 4. Informar al fabricante Airbus y realizar un seguimiento de cualquier información distribuida por Airbus sobre este problema.
EVELOP Airlines
Boletín de Seguridad Operacional #18—Junio 2017
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PRECAUCIONES EN PLATAFORMA
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PROMOCIÓN—SISTEMA INTERNO DE REPORTES Nueva edición 2.0—Enero 2017
Guía del Sistema Interno de Reportes para el personal de EVELOP & ORBEST. Consúltala en el correo electrónico que fue enviado a todo el personal o en la Intranet o Crew Web, en el site de Seguridad Operacional >> Guías & formularios.
EVELOP Airlines
Boletín de Seguridad Operacional #18—Junio 2017